The Politics of Emergency Medicine

by Lauren Hasek

In 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed, guaranteeing that patients requiring emergency medical care could not be turned away, regardless of citizenship, legal status, or inability to pay. While this is the closest thing to universal health care that the U.S. offers, currently 55 percent of emergency care goes uncompensated, estimated by Congress to be approximately $43 billion in 2008. This “free-rider problem” – the burden of those who receive health care free of charge because they are unable to pay – puts undue stress on the current system, where “the increasing frequency of emergency room visits for non-emergency treatment” is a direct cause of rising health costs.

Although the Patient Protection and Affordable Care Act (PPACA) is meant to create universal coverage, this cannot be realized for a number of reasons. While the act mandates coverage for all, the Congressional Budget Office estimates that in a decade, 30 million people will remain uninsured even though the plan will have been fully implemented. There are concerns that the penalties for going without health coverage will cost less than coverage itself, if they are enforced at all. While the expansion of Medicaid eligibility was expected to cover up to half of the uninsured, the Supreme Court recently ruled that states are not required to expand their Medicaid programs, making this coverage unlikely. While PPACA will decrease the number of Americans without medical coverage, the crisis of the uninsured is far from over. The ER will remain a key example of underfunded care, as it becomes a common primary care alternative for many Medicare and Medicaid patients.

Since physicians are only compensated for approximately 60 percent of what private insurance pays for these patients’ care, many therefore choose to only offer limited services, driving some patients to the ER alternative. While this is an immediate health care concern, very little research is being conducted to draw attention to this problem. With such stress placed on emergency medicine, the system could benefit from increased research that could then be translated into funding and policy initiatives to benefit ER care. Emergency medicine researchers receive less than 1 percent of NIH funding despite a 32 percent increase in ER visits over the past decade. Emergency medical care is underfunded and overcrowded; any claim that it is a replacement for insured health care is ludicrous. The PPACA does have the ability to partially alleviate the free-rider problem by increasing the number of total insured. Unfortunately, the population covered under Medicare and Medicaid expansions will still be pushed to the ER.

One fix could be to reimburse hospitals for EMTALA care. Even though this doesn’t appear to be on either candidate’s agenda, a series of independent small-scale urgent care centers and “minute clinics” are redefining health care by offering low cost, timely services, and functioning at odd hours. They are often staffed by a nurse and nurse practitioner, and accept cash and most insurance plans. A recent article from the National Center for Policy Analysis claims that one in five ER visits can be treated at urgent care centers, reducing annual healthcare costs by up to $4.4 billion. The use of these care centers is expected to accelerate due to the stress of implementing the PPACA over the next few years.